Nutriviva Client Health Assessment Form

Please enter your name.
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Age
Please provide your home phone number.
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Address
Please enter your complete address.
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Country
What is the main reason(s) for your visit or primary health goal(s)?
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How would you describe your general energy levels on most days?
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On average, how many hours of sleep do you get per night?
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How would you describe your typical sleep patterns?
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How many glasses of water do you usually drink per day?
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How many cups of herbal tea do you usually drink per week?
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How many cups of coffee do you usually drink per week?
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How often do you drink alcoholic beverages?
The Foods & Drinks I most often crave are:
The times I tend to crave these foods are:
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If applicable, do you notice that your cravings change around your menstrual cycle?
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Does your energy generally fluctuate with the time of day or other environmental factors?
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On average, how often do you have bowel movements?
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Do you cook mostly for yourself, or are you responsible for cooking for others in your household?
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Does that impact your eating habits or food choices?
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Are you regularly exposed to chemicals or contaminants at work or at home?
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Are there any foods or drinks you won’t or can’t eat?
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Do you have a regular relaxation or mindfulness practice?
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If yes, what type(s) of relaxation or mindfulness practice do you do, and how often?
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Describe your current health and lifestyle challenges.
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Describe your typical breakfast choices, portions, frequency and times.
Describe your typical lunch choices, portions, frequency and times.
Describe your dinner choices, portions, frequency and times.
Please enter your physician’s name or clinic name. (If applicable)
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List other health practitioners you visit regularly or occasionally. (If applicable)
Please describe any diagnosed illnesses or diseases. (If applicable)
Please list all medications, their use, and indications. (If applicable)
Describe natural products you take and their purposes. (If applicable)
Please describe any other relevant health issues. (If applicable)
Is there anything else you would like to discuss?
Confidentiality Waiver
All information shared during consultations is strictly confidential. Your personal health history, dietary information, and wellness goals will never be shared with any third party without your written consent, except where required by law.

Liability Waiver
Nutriviva’s nutritional guidance is intended for educational and wellness-support purposes only and is not a substitute for medical advice, diagnosis, or treatment. Clients should consult their physician regarding any medical conditions or concerns. By working with Nutriviva, you acknowledge that you are responsible for your own health decisions and outcomes, and you agree to release the practitioner from any liability related to the use or application of nutritional recommendations.

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